Provider Demographics
NPI:1922174515
Name:WITT, THERESA A (CNS)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:A
Last Name:WITT
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:1900 S NATIONAL AVE
Practice Address - Street 2:SUITE 3400
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2265
Practice Address - Country:US
Practice Address - Phone:417-820-3960
Practice Address - Fax:417-820-3966
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO089461364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
431560263021OtherTRICARE
P00225992OtherRAILROAD MEDICARE
MO429413909Medicaid
MOQ42010Medicare UPIN
MO429413909Medicaid